Endoscopic cholangiography and stone removal prior to cholecystectomy. A more cost-effective approach than operative duct exploration?

Would economic benefit result from performing endoscopic cholangiography and removal of common bile duct stones prior to cholecystectomy in patients who are suspected preoperatively of having choledocholithiasis? In this study, 173 patients had cholecystectomy and 30 (17%) had common bile duct exploration. Records of these patients were reviewed as were those of 31 patients who had only endoscopic cholangiography and endoscopic stone removal. Cost estimates were based on local charges. Cholecystectomy with common bile duct exploration was $6730 more per patient than cholecystectomy alone. Endoscopic cholangiography and endoscopic stone removal was 87% successful in removing duct stones. Had endoscopic cholangiography and endoscopic stone removal been performed preoperatively in patients undergoing cholecystectomy who had suspected choledocholithiasis, 21 of 30 common bile duct explorations could theoretically have been eliminated. This would have saved $85,526 or $2851 per patient undergoing common bile duct exploration. Our analysis suggests that patients who require cholecystectomy and have suspected choledocholithiasis may be treated more cost-effectively by performing endoscopic cholangiography and endoscopic stone removal immediately prior to cholecystectomy than by cholecystectomy and operative common bile duct exploration.     

Laparoscopic common bile duct exploration and cholecystectomy versus endoscopic stone extraction and laparoscopic cholecystectomy for choledocholithiasis. A prospective randomized study

BACKGROUND: Our objective is to compare the results of laparoscopic cholecystectomy (LC) and common bile duct (CBD) exploration to those of endoscopic stone extraction and LC in patients with CBD lithiasis based on a prospective randomized study. METHODS: From April 1997 until August 2000, 78 patients were assigned in two groups. Group A (n'36) patients underwent laparoscopic either direct or trancystic duct, CBD exploration and LC. Group B (n'42) patients were referred for endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) for duct clearance and at a later stage LC was performed. Selection of patients of both groups was done, considering prognostic factors of a preliminary study. RESULTS: Laparoscopic duct clearance was achieved in 85.7% of patients while the respective percentage for the combined approach was 84.3%. CONCLUSIONS: Laparoscopic CBD exploration is not yet established as the gold standard procedure for choledocholithiasis and there is the need for further randomized trials and possibly future meta-analyses.     

Laparoscopic transcystic common bile duct exploration versus transgastric endoscopic retrograde cholangiography during cholecystectomy after Roux-en-Y gastric bypass

BackgroundTreatment of common bile duct (CBD) stones after Roux-en-Y gastric bypass (RYGB) poses a particular challenge given the altered anatomy and inability to perform a standard endoscopic retrograde cholangiogram (ERC). The optimal treatment strategy for intraoperatively encountered CBD stones in post-RYGB patients has not been established.ObjectivesTo compare outcomes following laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopy-assisted transgastric ERC for CBDs during cholecystectomy in RYGB-operated patients.SettingSwedish nationwide multi-registry study.MethodsThe Swedish Registry for Gallstone Surgery and ERCs, GallRiks (n = 215,670), and the Scandinavian Obesity Surgery Registry (SOReg) (n = 60,479) were cross-matched for cholecystectomies with intraoperatively encountered CBD stones in patients with previous RYGB surgery between 2011 and 2020.ResultsRegistry cross-matching found 550 patients. Both LTCBDE (n = 132) and transgastric ERC (n = 145) were comparable in terms of low rates of intraoperative adverse events (1% versus 2%) and postoperative adverse events within 30 days (16% versus 18%). LTCBDE required significantly shorter operating time (P = .005) by on average 31 minutes, 95% confidence interval (CI) [10.3–52.6], and was more often used for smaller stones <4 mm in size (30% versus 17%, P = .010). However, transgastric ERC was more often used in acute surgery (78% versus 63%, P = .006) and for larger stones >8 mm in size (25% versus 8%, P < .001).ConclusionsLTCBDE and transgastric ERC have similarly low complication rates for clearance of intraoperatively encountered CBD stones in RYGB-operated patients, but LTCBDE is faster while transgastric ERC is more often used in conjunction with larger bile duct stones.     

Laparoscopic common bile duct exploration after failed endoscopic stone extraction

BACKGROUND: Our objective was to present the technical aspects and results of laparoscopic common bile duct (CBD) exploration following failed endoscopic stone extraction. METHOD: From April 1997 to December 2006, 32 patients were referred to us after unsuccessful attempts at endoscopic CBD stone extraction. Transcholedochal laparoscopic CBD exploration was used in all patients. Previous operations, several pathologic entities, and stone impaction were studied as potential predictors of failure of the laparoscopic approach. RESULTS: Previous operations, cholangitis, anatomic abnormalities, and stone impaction were the principal reasons for failure of endoscopic retrograde cholangiopancreatography (ERCP). Stone extraction under direct laparoscopic choledochotomy was achieved in 20 of 31 patients (64.51%). Biliary stents were inserted in 7 patients (21.8%) and T tubes were placed in 21 patients (65.6%). Five laparoscopic choledochoduodenostomies were performed. There were 11 conversions to open surgery. Morbidity was 12.5%. CONCLUSIONS: Laparoscopic choledochotomy is an efficacious procedure in dealing with unsuccessful endoscopic CBD clearance.     

一期腹腔镜胆囊切除联合胆总管探查取石与分期内镜取石和腹腔镜胆囊切除术治疗胆囊结石合并胆总管结石的比较

目的:比较一期腹腔镜胆囊切除(LC)联合胆总管探查取石(LCBDE)与分期内镜取石(ERCP)和LC治疗胆囊结石合并胆总管结石的临床效果。方法:回顾性分析2013年1月—2014年6月在西安交通大学第一附属医院行微创治疗的112例胆囊结石合并胆总管结石患者资料,其中52例行一期LC+LCBDE(LCBDE组),60例行ERCP后24 h或择期行LC(ERCP组),比较两组相关临床指标。结果:除LCBDE组平均年龄小于ERCP组外(42.4岁vs.57.4岁,P0.05),两组其余一般资料均具有可比性。两组均无死亡病例,手术成功率(94.3%vs.98.4%)、总并发症发生率(8.2%vs.10.1%)、结石残余发生率(2.0%vs.1.7%)等差异均无统计学意义(P0.05);ERCP组术后高淀粉酶血症发生率明显高于LCBDE组(16.9%vs.4.1%,P0.05),但均为单纯性淀粉酶升高;与ERCP组比较,LCBDE组术后住院时间更短(4.9 d vs.6.3 d),总住院费用减少(21 685.9元vs.30 354.3元),但LCBDE组手术时间明显延长(117.1 min vs.97.4 min)(均P0.05)。结论:一期LC+LCBDE或分期ERCP+LC治疗胆囊结石合并胆总管结石均安全、有效,可根据患者情况选择应用。     

Routine early endoscopic cholangiography, sphincterotomy and removal of common duct stones in acute gallstone pancreatitis.

OBJECTIVE--To study the efficacy, safety and timing of endoscopic retrograde cholangiography (ERC) and sphincterotomy in patients with acute gallstone pancreatitis. DESIGN--Open study in Tampere University Hospital, Finland. SUBJECTS--45 consecutive patients with acute gallstone pancreatitis who underwent ERC, with or without sphincterotomy. MAIN OUTCOME MEASURES--The results of early, compared with late, ERC with or without sphincterotomy. RESULTS--ERC was successful in all 45 patients. Ampullary impacted stone was found in eight. Common duct stones were found in 21 (47%) and sphincterotomy was successful in 19 of these (90%). Nine patients developed complications (20%), five of the nine in whom severe disease had been predicted (56%) and four of the 36 in whom mild disease had been predicted (11%, p < 0.01). Three patients required operations for necrotising pancreatitis, in two of whom sphincterotomy had failed. There was no difference in outcome between the 21 patients who had ERC with or without sphincterotomy within 72 hours (median 48 h) of the onset of symptoms and the 24 in whom it was delayed for a median of 144 hours. CONCLUSION--ERC and sphincterotomy may be done safely as a routine in patients with acute gallstone pancreatitis, and delay for a median of six days (range 3-14) from the onset of symptoms did not seem to affect the outcome in our patients.     

腹腔镜胆总管探查术与内镜下十二指肠乳头括约肌切开术治疗胆总管结石比较

目的 评价腹腔镜胆总管探查术(LCBDE)和内镜下十二指肠乳头括约肌切开术(EST)及其联合腹腔镜胆囊切除术(LC)的临床疗效.方法 回顾分析2005年9月至2009年1月本院普外科83例胆总管结石合并胆囊疾病患者的临床资料,其中行LCBDE术48例、EST-LC术35例.结果 两种术式手术成功率、手术时间、结石大小、术后并发症发生率、残余结石、结石复发比较差异无统计学意义(P＞0.05),结石数量、术后疼痛、住院费用、术后住院时间比较差异有统计学意义(P<0.05).结论 LCBDE和EST-LC两种微创手术成功率高、安全、并发症少、患者痛苦少、临床疗效可靠,是治疗胆总管结石合并胆囊疾病的理想手术.     

腔镜胆总管切开取石与内镜乳头括约肌切开取石术的远期疗效比较

目的 探讨腹腔镜胆总管切开取石术(laparoscopic common bile duct exploration,LCBDE)治疗胆总管结石的优越性.方法 回顾分析2001年6月至2006年6月间,在贵港市人民医院及广西壮族自治区人民医院微创中心行微创手术治疗的胆总管结石的临床资料.按手术方式不同分两组,即LCBDE组和EST(内镜乳头括约肌切开取石术,endoscopic sphincterotomy)组,比较两组的远期疗效.结果 该组225例,其中LCBDE 106例,EST 119例.术后随访1～6年,平均(3.2±0.8)年.LCBDE组结石复发率为3.77%(4/106),反流性胆管炎的发生率为2.83%(3/106),无乳头狭窄;EST组结石复发率为11.76%(14/119),乳头狭窄的发生率为7.56%(9/119),反流性胆管炎的发生率为12.61%(15/119).全组病例无胆管癌发生.术后结石复发率、乳头狭窄和反流性胆管炎的发生率在两组间的差别均有统计学意义.结论 在治疗胆总管结石方面,LCBDE的远期疗效优于EST.     

Single-incision laparoscopic cholecystectomy with routine intraoperative cholangiography and common bile duct exploration via the umbilical port

Background  

Laparoscopic cholecystectomy currently is the gold standard technique for gallbladder removal. The use of routine intraoperative cholangiography (IOC) is widely practiced during conventional four-port laparoscopic cholecystectomy (4PLC) to confirm biliary anatomy and allow for immediate management of unexpected choledocholithiasis. Single-incision laparoscopic surgery (SILS) offers a more aesthetic technique for gallbladder removal and has been reported by several groups. However, no series to date have included routine IOC without a separate incision. This study aimed to demonstrate the feasibility of the SILS technique for cholecystectomy with routine IOC (LCIOC) and common bile duct (CBD) exploration as needed via the umbilical port.     

腹腔镜胆总管切开取石治疗胆总管结石的疗效观察

目前腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）已经成为治疗胆囊炎、胆囊结石的金标准。胆总管结石在我国的发病率较高，占全国胆结石患者的5％～29％，平均18％。我院在成熟开展LC的基础上于2005年9月开展腹腔镜胆总管切开探查取石术（laparoscopic video choledochoibersc opichepatocholangiolitbotomy T—tubedrainage，LCHTD），就其手术经验及疗效分析报道如下。     

Failure of endoscopic removal of common bile duct stones due to endo-clip migration following laparoscopic cholecystectomy

We report herein an extremely rare complication; namely, endo-clip migration into the common bile duct, following laparoscopic cholecystectomy, that occurred in a 57-year-old man. He underwent laparoscopic cholecystectomy, but postoperative bile leakage occurred from the cystic duct stump and he was treated by conservative drainage for 1 month. Five years later, he complained of vomiting and pain in the right hypochondrium, and he was admitted for investigations of jaundice and liver dysfunction. Computerized tomography scanning of the abdomen and endoscopic retrograde cholangiography revealed that several calculi, with six endo-clips as nuclei, had migrated into the biliary tract. Endoscopic removal of the calculi following endoscopic sphincterotomy, using a basket catheter, was unsuccessful, and it was therefore necessary to remove the basket catheter surgically. The mechanism of endo-clip migration and the method for removing the endo-clips are briefly discussed. Received: September 21, 2001 / Accepted: February 8, 2002     

2型糖尿病患者行腹腔镜胆总管切开取石术临床研究

目的:探讨胆总管结石合并2型糖尿病患者行腹腔镜胆总管切开取石术(LCBDE)的可行性、安全性及有效性.方法:回顾性分析2009年12月-2012年12月采用LCBDE治疗的58例合并2型糖尿病(糖尿病组)及同期58例无糖尿病(非糖尿病组)胆总管结石患者的临床资料,比较两组术前、术中及术后的情况.结果:两组患者手术时间、术中出血量、开始进食时间、术后住院时间及中转开腹方面,差异均无统计学意义(t/x 2=3.921,6.940,1.332,1.270,0.342,均P＞0.05).两组术后电解质紊乱、胆管炎、胆瘘、切口感染、肺部感染发生率比较,差异亦均无统计学意义(×2=0.438,0.537,0.342,1.036,0.342,均P＞0.05).两组均无术后结石残余、胆管狭窄及死亡病例.结论:合并2型糖尿病的胆总管结石患者在围手术期严格控制血糖,术中仔细操作的前提下,行LCBDE是可行的、安全的、有效的.     

腹腔镜下胆道探查与内镜Oddi括约肌切开取石的研究

目的:探讨腹腔镜胆道探查取石,T管引流术和腹腔镜胆囊切除一期联合内镜Oddi括约肌切开取石治疗胆总管结石合并胆囊结石的临床应用价值。方法:统计分析研究组(77例腹腔镜胆道探查取石即LCH- TD及43例腹腔镜胆囊切除一期联合内镜Oddi括约肌切开取石即LC- EST)与对照组(60例常规开腹胆总管探查即OCHTD)胆总管结石合并胆囊结石患者的临床资料。结果:研究组胆总管结石合并胆囊结石120例中111例行微创手术取得成功,占92. 5%,与对照开腹探查组相比,术后恢复较好,住院时间短,取得了较满意的效果(P<0 .05);研究组中运用LCH -TD的患者较LC EST的患者手术操作时间、术后腹痛、恶心及住院天数差异有显著性(P<0. 05)。两者在胆总管内径及结石大小方面差异亦有显著性(P<0. 05)。结论:LCH -TD与LC -EST两种术式微创,安全且临床疗效可靠,能代替大部分开腹胆总管探查术;腹腔镜胆总管探查取石法总体上优于腹腔镜胆囊切除一期联合内镜Oddi括约肌切开取石法。胆总管直径>1 0cm者行LCH- TD是一种安全可行的方法。若胆总管内径<1cm,且胆总管结石<1 0cm,建议行LC- EST。     

Techniques for laparoscopic cholangiography and removal of common duct stones

As laparoscopic cholecystectomy becomes more prevalent, the unexpected finding of common duct stones by operative cholangiography presents a therapeutic dilemma for the surgeon. We present our current techniques for laparoscopic cholangiography and management of choledocholithiasis, including the use of angioplasty balloons for ampullary dilation.     

小切口胆囊切除胆总管探查的体会

目的 探讨小切口胆囊切除胆总管探查的方法，临床应用价值及适应证。方法 分析小切口胆囊切除胆总管探查56例的临床资料。结果 除2例延长切口外54例都顺利完成手术，无术后并发症，术后切口疼痛轻，肠功能恢复早。结论 小切口胆囊切除胆总管探查是可行的，但要有一定的适应证，必须有安全第一的思想，必要时延长切口。